Internal Ventricular Cerebrospinal Fluid Shunt for Adult Hydrocephalus: A Systematic Review and Meta-Analysis of the Infection Rate

Hydrocephalus is a common neurological condition that usually requires internal ventricular cerebrospinal fluid shunt (IVCSFS). The reported infection rate (IR) varies greatly from below 1% up to over 50%, but no meta-analysis to assess the overall IR has ever been performed.

OBJECTIVE: To determine the IVCSFS overall IR in the adult population and search for associated factors.

METHODS: Six databases were searched from January 1990 to July 2022. Only original articles reporting on adult IVCSFS IR were included. Random-effects meta-analysis with generalized linear mixed model method and logit transformation was used to assess the overall IR. RESULTS: Of 1703 identified articles, 44 were selected, reporting on 57259 patients who had IVCSFS implantation and 2546 infections. The pooled IR value and its 95% CI were 4.75%, 95% CI (3.8 to 5.92). Ninety-five percent prediction interval ranged from 1.19% to 17.1%. The patients who had IVCSFS after intracranial hemorrhage showed a higher IR (7.65%, 95% CI [5.82 to 10], P-value = .002). A meta-regression by year of publication found a decreasing IR (À0.031, 95% CI [À0.06 to 0.003], P-value = .032) over the past 32 years.

CONCLUSION: IVCSF is a procedure that every neurosurgeon should be well trained to perform. However, the complication rate remains high, with an estimated overall IR of 4.75%. The IR is especially elevated for hydrocephalic patients who require IVCSFS after intracranial hemorrhage. However, decades of surgical advances may have succeeded in reducing IR over the past 32 years.

Neurosurgery 92:894–904, 2023

First Experience With Postoperative Transcranial Ultrasound Through Sonolucent Burr Hole Covers in Adult Hydrocephalus Patients

Neurosurgery 92:382–390, 2023

Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull.

OBJECTIVE: To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients.

METHODS: Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy.

RESULTS: Thirty-seven patients with sonolucent burr hole cover were compared with 57 historical control patients. There was no statistically significant difference in infection rates between the sonolucent burr hole cover group (1/37, 2.7%) and the control group (0/57, P = .394). Revision rates were 13.5% vs 15.8% (P = 1.000), but no revisions were related to the burr hole or cranial hardware.

CONCLUSION: Trans-burr hole ultrasound is feasible for gross evaluation of ventricular caliber postoperatively in patients with sonolucent burr hole covers. There was no increase in infection rate or revision rate. This imaging technique may serve as an alternative to CT and MRI in the management of select patients with hydrocephalus and CSF disorders.

Failure of Internal Cerebrospinal Fluid Shunt: A Systematic Review and Meta-Analysis of the Overall Prevalence in Adults

World Neurosurg. (2023) 169:20-30

Reported rates of failures of internal cerebrospinal fluid shunt (ICSFS) vary greatly from less than 5% to more than 50% and no meta-analysis to assess the overall prevalence has been performed. We estimated the failure rate after ICSFS insertion and searched for associated factors.

METHODS: Six databases were searched from January 1990 to February 2022. Only original articles reporting the rate of adult shunt failure were included. Random-effects meta-analysis with a generalized linear mixed model method and logit transformation was used to compute the overall failure prevalence. Subgroup analysis and meta-regression were implemented to search for associated factors.

RESULTS: Of 1763 identified articles, 46 were selected, comprising 70,859 ICSFS implantations and 13,603 shunt failures, suggesting an accumulated incidence of 19.2%. However, the calculated pooled prevalence value and its 95% confidence interval (CI) were 22.7% (95% CI, 19.8e5.8). The CI of the different estimates did not overlap, indicating a strong heterogeneity confirmed by a high I 2 of 97.5% (95% CI, 97.1e97.8; P < 0.001; s 2 [ 0.3). Ninety-five percent prediction interval of shunt failure prevalence ranged from 8.75% to 47.36%. A meta-regression of prevalence of publication found a barely significant decreasing failure rate of about 2% per year (e2.11; 95% CI, e4.02 to e0.2; P [ 0.031).

CONCLUSIONS: Despite being a simple neurosurgical procedure, ICSFS insertion has one of the highest risk of complications, with failure prevalence involving more than 1 patient of 5. Nonetheless, all efforts to lower this high level of shunt failure seem to be effective.

Permanent Cerebrospinal Fluid Diversion in Adults With Posterior Fossa Tumors: Incidence and Predictors


Neurosurgery 89:987–996, 2021

Posterior fossa tumors (PFTs) can cause hydrocephalus. Hydrocephalus can persist despite resection of PFTs in a subset of patients requiring permanent cerebrospinal fluid (CSF) diversion. Characteristics of this patient subset are not well defined.

OBJECTIVE: To define preoperative and postoperative variables that predict the need for postoperative CSF diversion in adult patients with PFTs.

METHODS: We surveyed the CNS (Central Nervous System) Tumor Outcomes Registry at Emory (CTORE) for patients who underwent PFT resection at 3 tertiary-care centers between 2006 and 2019. Demographic, radiographic, perioperative, and dispositional data were analyzed using univariate and multivariate models.

RESULTS:We included 617 patients undergoing PFT resection for intra-axial (57%) or extraaxial (43%) lesions. Gross total resection was achieved in 62% of resections. Approximately 13% of patients required permanent CSF diversion/shunting. Only 31.5% of patients who required pre- or intraop external ventricular drain (EVD) placement needed permanent CSF diversion. On logistic regression, size, transependymal flow, use of perioperative EVD, postoperative intraventricular hemorrhage (IVH), and surgical complications were predictors of permanent CSF diversion. Preoperative tumor size was only independent predictor of postoperative shunting in patients with subtotal resection. In patients with intra-axial tumors, transependymal flow (P = .014), postoperative IVH (P = .001), surgical complications (P = .013), and extent of resection (P = .03) predicted need for shunting. In extra-axial tumors, surgical complications were the major predictor (P = .022).

CONCLUSION: Our study demonstrates that presence of preoperative hydrocephalus in patients with PFT does not necessarily entail the need for permanent CSF diversion. We report the major predictive factors for needing permanent CSF diversion.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Treatment of Pediatric Hydrocephalus: Update of the 2014 Guidelines

Neurosurgery 87:1071–1075, 2020

The Congress of Neurological Surgeons reviews its guidelines according to the Institute of Medicine’s recommended best practice of reviewing guidelines every 5 yrs. The authors performed a planned 5-yr review of the medical literature used to develop the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines” and determined the need for an update to the original guideline based on new available evidence.

OBJECTIVE: To perform an update to include the current medical literature for the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines”, originally published in 2014.

METHODS: The Guidelines Task Force used the search terms and strategies consistent with the original guidelines to search PubMed and Cochrane Central for relevant literature published between March 2012 and November 2019. The same inclusion/exclusion criteria were also used to screen abstracts and to perform the full-text review. Full text articles were then reviewed and when appropriate, included as evidence and recommendations were added or changed accordingly.

RESULTS: A total of 41 studies yielded by the updated search met inclusion criteria and were included in this update.

CONCLUSION: New literature resulting from the update yielded a new recommendation in Part 2, which states that neuro-endoscopic lavage is a feasible and safe option for the removal of intraventricular clots and may lower the rate of shunt placement (Level III). Additionally a recommendation in part 7 of the guideline now states that antibiotic- impregnated shunt tubing reduces the risk of shunt infection compared with conventional silicone hardware and should be used for children who require placement of a shunt (Level I). < hydrocephalus-guideline>

Thirty-Day Hospital Readmission and Surgical Complication Rates for Shunting in Normal Pressure Hydrocephalus: A Large National Database Analysis

Neurosurgery 86:843–850, 2020

Research on age-related complications secondary to shunts in normal pressure hydrocephalus (NPH) is primarily limited to single-center studies and small cohorts.

OBJECTIVE: To determine the rates of hospital readmission and surgical complications, and factors that predict them, following shunt surgery for NPH in a large healthcare network.

METHODS: Surgical procedures, complications, and readmissions for adults undergoing ventricular shunting for NPH were determined using de-identified claims from a privately insured United States healthcare network in years 2007-2014. Univariate and multivariate statistics were used to determine factors that predict poor surgical outcomes. The primary outcome variable was surgical complications or readmissions (composite variable for any major perioperative complication or 30-d readmission).

RESULTS: The 30-d readmission rate for 974 patients with NPH who underwent ventricular shunting was 7.29%; the most common reasons for readmission were shunt-related complications, infection, hemorrhage, altered mental status, and cardiopulmonary and musculoskeletal problems. The perioperative complication rate was 21.15%, including intraparenchymal hemorrhage (5.85%) and extra-axial (subdural or epidural) hematoma (5.54%). The overall rate of having a surgical complication or 30-d readmission was 25.15%. Age did not predict surgical complication or 30-d readmission. Preoperative comorbidities independently associated with poor outcome were myocardial infarction within 1 yr (OR = 3.984, 95% CI = 1.105-14.368); existing cerebrovascular disease (odds ratio [OR] = 2.206, 95% CI = 1.544-3.152); and moderate/severe renal disease (OR = 2.000, 95% CI = 1.155-3.464).

CONCLUSION: The rate of complications or readmission within 30 d of ventricular shunting for NPH is 25.15%. Preoperative comorbidities of myocardial infarction within 1 yr, cerebrovascular disease, and moderate/severe renal disease are independent risk factors for poor outcome.

Cranial dural arteriovenous shunts: selection of the ideal lesion for surgical occlusion according to the classification system

Acta Neurochirurgica (2019) 161:1775–1781 

The types of cranial dural arteriovenous fistulae (cDAVFs) that constitute good surgical candidates are unclear despite the use of classifications. We aimed to compare the DES classification with other classification schemes in identifying “ideal lesions for surgery.” The DES scheme is based on two features: the level of the shunt (BVS, bridging vein shunt; DSS, dural sinus shunt; ISS, isolated sinus shunt; EVS, emissary vein shunt) and the type of leptomeningeal venous reflux (LVR) (direct, exclusive, strained).

In this observational cohort study, the angiographies of 20 consecutive patients treated over 1 year were analyzed retrospectively. We defined cDAVFs as ideal for surgery, if cure may be achieved by disconnecting the arterialized draining vein through a single craniotomy. To evaluate the performance of each classification scheme in identifying the “ideal lesion for surgery,” we carried out a sensitivity analysis of the Borden, Cognard, and DES schemes.

Eight lesions were Borden type 3 and 1 type 2, and 11 type 1. According to Cognard, 2 lesions were type IV, 2 type III, 1 type IIa+b, 11 type I, and 4 lesions could not be clearly classified. According to the DES scheme, 8 lesions were DSS, 4 BVS, 3 ISS, and 5 EVS. All 4 lesions classified as BVS in the DES were ideal lesions for surgery (sensitivity, specificity, PPV, NPV 100%). Not all high-grade lesions according to Borden were good surgical candidates.

Conclusion The DES scheme, as opposed to other classifications, facilitates the therapeutic decision-making especially for selecting candidates for surgery.

Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: Predictors and Long-Term Functional Outcomes

Neurosurgery 83:393–402, 2018

Although chronic hydrocephalus requiring shunt placement is a known sequela of aneurysmal subarachnoid hemorrhage (aSAH), its effect on long-term functional outcomes is incompletely understood.

OBJECTIVE: To identify predictors of shunt-dependent hydrocephalus and shunt complications after aSAH and determine the effect of shunt dependence on functional outcomes in aSAH patients.

METHODS: We evaluated a database of patients treated for aSAH at a single center from 2000 to 2015. Favorable and unfavorable outcomes were defined as modified Rankin Scale grades 0 to 2 and 3 to 6, respectively. We performed statistical analyses to identify variables associated with shunt-dependent hydrocephalus, unfavorable outcome, and shunt complication.

RESULTS: Of the 888 aSAH patients, 116 had shunt-dependent hydrocephalus (13%). Older age (P = .001), intraventricular hemorrhage (IVH) (P = .004), higher World Federation of Neurological Surgeons (WFNS) grade (P < .001), surgical aneurysm treatment (P = .002), and angiographic vasospasm (P=.005) were independent predictors of shunt-dependent hydrocephalus in multivariable analysis. Functional outcome was evaluable in 527 aSAH patients (mean follow-up 18.6 mo), with an unfavorable outcome rate of 17%. Shunt placement (P < .001), shunt infection (P = .041), older age (P < .001), and higher WFNS grade (P = .043) were independently associated with an unfavorable outcome in multivariable analysis. Of the shunt-dependent patients, 18% had a shunt-related complication. Higher WFNS grade (P= .011), posterior circulation aneurysm (P= .018), and angiographic vasospasm (P=.008)were independent predictors of shunt complications inmultivariable analysis.

CONCLUSION: aSAH patients with shunt-dependent hydrocephalus have significantly poorer long-term functional outcomes. Patients with risk factors for post-aSAH shunt dependence may benefit from increased surveillance, although the effect of such measures is not defined in this study.

Predictors of admission and shunt revision during emergency department visits for shunt-treated adult patients with idiopathic intracranial hypertension

J Neurosurg 127:233–239, 2017

Factors associated with emergency department admission and/or shunt revision for idiopathic intracranial hypertension (IIH) are unclear. In this study, the associations of several factors with emergency department admission and shunt revision for IIH were explored.

METHODS The authors performed a retrospective review of 31 patients (169 total emergency department visits) who presented to the emergency department for IIH-related symptoms between 2003 and 2015. Demographics, comorbidities, symptoms, IIH diagnosis and treatment history, ophthalmological examination, diagnostic lumbar puncture (LP), imaging findings, and data regarding admission and management decisions were collected. Multivariable general linear models regression analysis was performed to assess the predictive factors associated with admission and shunt revision.

RESULTS Thirty-one adult patients with a history of shunt placement for IIH visited the emergency department a total of 169 times for IIH-related symptoms, with a median of 3 visits (interquartile range 2–7 visits) per patient. Five patients had more than 10 emergency department visits. Baseline factors associated with admission included male sex (OR 10.47, 95% CI 2.13–51.56; p = 0.004) and performance of an LP (OR 3.10, 95% CI 1.31–7.31; p = 0.01). Contrastingly, older age at presentation (OR 0.94, 95% CI 0.90–0.99; p = 0.01), and a greater number of prior emergency department visits (OR 0.94, 95% CI 0.89–0.99; p = 0.02) were slightly protective against admission. The presence of papilledema (OR 11.62, 95% CI 3.20–42.16; p < 0.001), Caucasian race (OR 40.53, 95% CI 2.49–660.09 p = 0.009), and systemic hypertension (OR 7.73, 95% CI 1.11–53.62; p = 0.03) were independent risk factors for shunt revision. In addition, a greater number of prior emergency department visits (OR 0.86, 95% CI 0.77–0.96; p = 0.009) and older age at presentation (OR 0.93, 95% CI 0.87–0.99; p = 0.02) were slightly protective against shunt revision, while there was suggestive evidence that presence of a programmable shunt (OR 0.23, 95% CI 0.05–1.14; p = 0.07) was a protective factor against shunt revision. Of note, location of the proximal catheter in the ventricle or lumbar subarachnoid space was not significantly associated with admission or shunt revision in the multivariable analyses.

CONCLUSIONS The decision to admit a shunt-treated patient from the emergency department for symptoms related to IIH is challenging. Knowledge of factors associated with the need for admission and/or shunt revision is required. In this study, factors such as male sex, younger age at presentation, lower number of prior emergency department visits, and performance of a diagnostic LP were independent predictors of admission. In addition, papilledema was strongly predictive of the need for shunt revision, highlighting the importance of an ophthalmological examination for shunt-treated adults with IIH who present to the emergency department.


Associations of intracranial pressure with brain biopsy, radiological findings, and shunt surgery outcome in patients with suspected idiopathic normal pressure hydrocephalus

Acta Neurochir (2017) 159: 51-61

It remains unclear how intracranial pressure (ICP) measures are associated with brain biopsies and radiological markers. Here, we aim to investigate associations between ICP and radiological findings, brain biopsies, and shunt surgery outcome in patients with suspected idiopathic normal pressure hydrocephalus (iNPH).


In this study, we retrospectively analyzed data from 73 patients admitted with suspected iNPH to Kuopio University Hospital. Of these patients, 71% underwent shunt surgery. The NPH registry included data on clinical and radiological examinations, 24-h intraventricular pressure monitoring, and frontal cortical biopsy.


The mean ICP and mean ICP pulse wave amplitude were not associated with the shunt response. Aggregations of Alzheimer’s disease (AD)-related proteins (amyloid-β, hyperphosphorylated tau) in frontal cortical biopsies were associated with a poor shunt response (P = 0.014). High mean ICP was associated with Evans’ index (EI; P = 0.025), disproportional sylvian and suprasylvian subarachnoid spaces (P = 0.014), and focally dilated sulci (P = 0.047). Interestingly, a high pulse wave amplitude was associated with AD-related biopsy findings (P = 0.032), but the mean ICP was not associated with the brain biopsy. The ICP was not associated with medial temporal lobe atrophy, temporal horn widths, or white matter changes. ICP B waves were associated with less atrophy of the medial temporal lobe (P = 0.018) and more severe disproportionality between the sylvian and suprasylvian subarachnoid spaces (P = 0.001).


The EI and disproportional sylvian and suprasylvian subarachnoid spaces were associated with mean ICP. Disproportionality was also associated with ICP B waves. These associations, although rather weak, with elevated ICP in 24-h measurements, support their value in iNPH diagnostics and suggest that these radiological markers are potentially related to the pathogenesis of iNPH. Interestingly, our results suggested that elevated pulse wave amplitude might be associated with brain amyloid accumulation.

Parametric study of ventricular catheters for hydrocephalus

Parametric study of ventricular catheters for hydrocephalus

Acta Neurochir (2016) 158:109–116

To drain the excess of cerebrospinal fluid in a hydrocephalus patient, a catheter is inserted into one of the brain ventricles and then connected to a valve. This so-called ventricular catheter is a standard-size, flexible tubing with a number of holes placed symmetrically around several transversal sections or “drainage segments”. Three-dimensional computational dynamics shows that most of the fluid volume flows through the drainage segment closest to the valve. This fact raises the likelihood that those holes and then the lumen get clogged by the cells and macromolecules present in the cerebrospinal fluid, provoking malfunction of the whole system. In order to better understand the flow pattern, we have carried out a parametric study via numerical models of ventricular catheters.

Methods The parameters chosen are the number of drainage segments, the distances between them, the number and diameter of the holes on each segment, as well as their relative angular position.

Results These parameters were found to have a direct consequence on the flow distribution and shear stress of the catheter. As a consequence, we formulate general principles for ventricular catheter design.

Conclusions These principles can help develop new catheters with homogeneous flow patterns, thus possibly extending their lifetime.

Long-term Functional Outcomes and Predictors of Shunt-Dependent Hydrocephalus After Treatment of Ruptured Intracranial Aneurysms in the BRAT Trial: Revisiting the Clip vs Coil Debate


Neurosurgery 76:608–615, 2015

Acute hydrocephalus is a well-known sequela of aneurysmal subarachnoid hemorrhage (SAH). Controversy exists about whether open microsurgical methods serve to reduce shunt dependency compared with endovascular techniques.

OBJECTIVE: To determine predictors of shunt-dependent hydrocephalus and functional outcomes after aneurysmal SAH.

METHODS: A total of 471 patients who were part of a prospective, randomized, controlled trial from 2003 to 2007 were retrospectively reviewed. All variables including demographic data, medical history, treatment, imaging, and functional outcomes were included as part of the trial. No additional variables were retrospectively collected.

RESULTS: Ultimately, 147 patients (31.2%) required a ventriculoperitoneal shunt (VPS) in our series. Age, dissecting aneurysm type, ruptured vertebrobasilar aneurysm, Fisher grade, Hunt and Hess grade, admission intraventricular hemorrhage, admission intraparenchymal hemorrhage, blood in the fourth ventricle on admission, perioperative ventriculostomy, and hemicraniectomy were significant risk factors (P < .05) associated with shunt-dependent hydrocephalus on univariate analysis. On multivariate analysis, intraventricular hemorrhage and intraparenchymal hemorrhage were independent risk factors for shunt dependency (P< .05). Clipping vs coiling treatment was not statistically associated with VPS after SAH on both univariate and multivariate analyses. Patients who did not receive a VPS at discharge had higher Glasgow Outcome Scale and Barthel Index scores and were more likely to be functionally independent and to return to work 72 months after surgery (P < .05).

CONCLUSION: There is no difference in shunt dependency after SAH among patients treated by endovascular or microsurgical means. Patients in whom shunt-dependent hydrocephalus does not develop after SAH tend to have improved long-term functional outcomes.

Gravity assisted vs. medium pressure valves for communicating hydrocephalus show similar valve-revision rates

Gravity assisted vs. medium pressure valves for communicating hydrocephalus show similar valve-revision rates

Acta Neurochir (2013) 155:1987–1991

Two common valve types used to treat hydrocephalus include gravity assisted valves (GAV) and medium pressure valves (MPV). Despite their different mechanism of action, differentiated surgical indications per type are not well defined. One could assume that due to a higher complexity of the GAV system, it may be more prone to valve-related malfunction. The purpose of this retrospective study was to compare the valve-related complication rates of GAV and MPV in patients with communicating hydrocephalus.

Method Patients aged 16 years or older undergoing their first shunt implantation using GAV or MPV were included. We recorded demographic data, implantation diagnosis, outcome, complications, valve type and valve adjustments. Symptoms were documented at discharge and follow-up. Valve-related malfunctions were distinguished from other shunt complications.

Results N =252 patients (range 16.6–88.4, mean 65.0 years, 116 male and 136 female) underwent shunt placement for the first time. N =122 GAV (48.4 %) and n =130 MPV were implanted (51.6 %) over a period of 5 years. The most frequent diagnoses were normal pressure hydrocephalus (NPH) in 86 cases (34.1 %) and posthemorrhagic hydrocephalus in 114 cases (45.2 %). About two thirds of patients were free of hydrocephalus-related symptoms at follow-up. N =66 subjects (26.2 %) underwent at least one shunt revision. N =29 revisions (11.5 %) were due to valve-related malfunction. Valve-related revisions were the main cause for revision in 18/37 cases (48.6 %) in the GAV group and in 11/29 (37.9 %) in the MPV group. Neither clinical improvement nor valve-related malfunctions were found to be statistically different among groups.

Conclusions Despite their technical differences, GAV and MPV show similar valve-related revision rates in the treatment of communicating hydrocephalus.

Is endoscopic third ventriculostomy superior to shunts in patients with non-communicating hydrocephalus?


Acta Neurochir (2013) 155:883–889

Endoscopic third ventriculostomy (ETV) and shunts are both utilized in the treatment of noncommunicating hydrocephalus. The objective of this study was to review the evidence comparing the effectiveness of these two techniques.

Methods The Cochrane Central Register of Controlled Trials (CENTRAL) and Medline databases were searched between 1990 and August 2012. We included all studies comparing the failure rate of patients with noncommunicating hydrocephalus treated with ETVand shunts. Two authors (HJM and FTR) appraised quality and extracted data independently.

Results Of 313 articles identified, 12 were selected for further review. Of these, 6 were included for qualitative analysis, and 5 for quantitative analysis (n=504). ETV was associated with a non-statistically significant reduction in failure using the random-effects model (OR 0.58, 95 % CI 0.29-1.13).

Conclusions Both ETV and shunts are associated with a relatively high failure rate. At present there is insufficient proof to unequivocally recommend one mode of treatment above the other. However, there is some evidence that ETV may confer long-term survival advantage over shunts in the treatment of non-communicating hydrocephalus, particularly in patients with certain aetiologies such as aqueductal stenosis. Prospective randomized controlled trials are currently underway and may provide more robust evidence to answer this important question and better guide future management.

Alteration of brain viscoelasticity after shunt treatment in normal pressure hydrocephalus

Neuroradiology (2012) 54:189–196. DOI 10.1007/s00234-011-0871-1

Normal pressure hydrocephalus (NPH) represents a chronic neurological disorder with increasing incidence. The symptoms of NPH may be relieved by surgically implanting a ventriculoperitoneal shunt to drain excess cerebrospinal fluid. However, the pathogenesis of NPH is not yet fully elucidated, and the clinical response of shunt treatment is hard to predict. According to current theories of NPH, altered mechanical properties of brain tissue seem to play an important role. Magnetic resonance elastography (MRE) is a unique method for measuring in vivo brain mechanics.

Methods In this study cerebral MRE was applied to test the viscoelastic properties of the brain in 20 patients with primary (N=14) and secondary (N=6) NPH prior and after (91±16 days) shunt placement. Viscoelastic parameters were derived from the complex modulus according to the rheological springpot model. This model provided two independent parameters μ and α, related to the inherent rigidity and topology of the mechanical network of brain tissue.

Results The viscoelastic parameters μ and α were found to be decreased with −25% and −10%, respectively, compared to age-matched controls (P<0.001). Interestingly, α increased after shunt placement (P<0.001) to almost normal values whereas μ remained symptomatically low.

Conclusion The results indicate the fundamental role of altered viscoelastic properties of brain tissue during disease progression and tissue repair in NPH. Clinical improvement in NPH is associated with an increasing complexity of the mechanical network whose inherent strength, however, remains degraded.

More malfunctioning Medos Hakim programmable valves: cause for concern?

J Neurosurg 115:1047–1052, 2011. DOI: 10.3171/2011.5.JNS101396

In recent years, the authors have noticed a growing number of programmable valve defects at their institution. Therefore, they conducted this study to evaluate the increased incidence of malfunctioning valves.

Methods. They investigated all revisions that had been performed at their institution between 1994 and 2010 for dislodgement of the stator of a standard Medos Hakim programmable valve with a prechamber.

Results. Fifteen valves were removed because of dislodged stators. The valves had been implanted between May 16, 1993, and December 27, 2002, and were explanted between February 19, 2006, and January 22, 2010. Thus, the valves had been in place for a mean period of 11 years (median 11 years, range 7–14 years). The percentage of dislodged stators was almost 3% (15 of 546 valves). Particularly noteworthy is that all malfunctioning valves were found in children who had been younger than 1 year of age at the time of implantation.

Conclusions. Medos Hakim programmable valve malfunctions are rare events but should receive careful attention. When the pressure setting cannot be adjusted, a malfunction should always be suspected and radiographic imaging should be performed to assess the valve. Stator dislodgement is the most serious form of valve adjustment failure.

A standardized protocol to reduce cerebrospinal fluid shunt infection: The Hydrocephalus Clinical Research Network Quality Improvement Initiative

J Neurosurg Pediatrics 8:22–29, 2011. DOI: 10.3171/2011.4.PEDS10551

Quality improvement techniques are being implemented in many areas of medicine. In an effort to reduce the ventriculoperitoneal shunt infection rate, a standardized protocol was developed and implemented at 4 centers of the Hydrocephalus Clinical Research Network (HCRN).

Methods. The protocol was developed sequentially by HCRN members using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied at each HCRN center to all children undergoing a shunt insertion or revision procedure. Infections were defined on the basis of CSF, wound, or pseudocyst cultures; wound breakdown; abdominal pseudocyst; or positive blood cultures in the presence of a ventriculoatrial shunt. Procedures and infections were measured before and after protocol implementation.

Results. Twenty-one surgeons at 4 centers performed 1571 procedures between June 1, 2007, and February 28, 2009. The minimum follow-up was 6 months. The Network infection rate decreased from 8.8% prior to the protocol to 5.7% while using the protocol (p = 0.0028, absolute risk reduction 3.15%, relative risk reduction 36%). Three of 4 centers lowered their infection rate. Shunt surgery after external ventricular drainage (with or without prior infection) had the highest infection rate. Overall protocol compliance was 74.5% and improved over the course of the observation period. Based on logistic regression analysis, the use of BioGlide catheters (odds ratio [OR] 1.91, 95% CI 1.19–3.05; p = 0.007) and the use of antiseptic cream by any members of the surgical team (instead of a formal surgical scrub by all members of the surgical team; OR 4.53, 95% CI 1.43–14.41; p = 0.01) were associated with an increased risk of infection.

Conclusions. The standardized protocol for shunt surgery significantly reduced shunt infection across the HCRN. Overall protocol compliance was good. The protocol has established a common baseline within the Network, which will facilitate assessment of new treatments. Identification of factors associated with infection will allow further protocol refinement in the future.

Variability among pediatric neurosurgeons in the threshold for ventricular shunting in asymptomatic children with hydrocephalus

J Neurosurg Pediatrics 7:000–000, 2011.DOI: 10.3171/2010.11.PEDS10275

The thresholds for shunting CSF in children with asymptomatic hydrocephalus are unclear; there are neither guidelines nor sufficient research to determine what degree of hydrocephalus should be treated. The authors hypothesize that 1) pediatric neurosurgeons currently have high thresholds for recommending treatment for these children, but 2) there is significant variability among these treatment thresholds.

Methods. The authors surveyed attendees of the Joint Pediatric Neurosurgery Section meeting in Spokane, Washington, in December 2008, regarding their treatment thresholds for 22 clinical scenarios. Each participant was provided an illustration of 5 imaging studies (3 slices each) showing progressively larger ventricles. For each scenario, respondents were asked to indicate the minimum ventricular size they would treat, if any. Responses were quantified from 1 to 6 from smaller to larger, with 6 being no treatment, and a mean theoretical treated ventricular size (MTTVS) was calculated for each scenario.

Results. Respondents were relatively conservative in recommending treatment, with MTTVSs of 3.7–6.0; in 13 scenarios, the MTTVS was greater than 5.0 (larger than the largest presented ventricular size). For scenarios in which a mean frontooccipital ratio could be calculated, the value ranged from 0.55 to 0.67 (moderate to severe hydrocephalus). Although there were clear majority responses for each scenario, there was also significant variability. There were no patterns of association with the respondent’s age, training, board certification, or type or location of practice.

Conclusions. This study demonstrates that pediatric neurosurgeons’ thresholds for treating asymptomatic children with hydrocephalus are generally high, but there is also significant variability.

Evaluation of the ShuntCheck Noninvasive Thermal Technique for Shunt Flow Detection in Hydrocephalic Patients

Neurosurgery 68:198–205, 2011 DOI: 10.1227/NEU.0b013e3181fe2db6

ShuntCheck (Neuro Diagnostic Devices, Inc., Trevose, Pennsylvania) is a new device designed to detect cerebrospinal fluid (CSF) flow in a shunt by sensing skin temperature downstream from a region of CSF cooled by an ice cube.

OBJECTIVE: To understand its accuracy and utility, we evaluated the use of this device during routine office visits as well as during workup for suspected shunt malfunction.

METHODS: One hundred shunted patients were tested, including 48 evaluated during possible shunt malfunction, of whom 24 went on to surgical exploration. Digitally recorded data were blindly analyzed and compared with surgical findings and clinical follow-up.

RESULTS: Findings in the 20 malfunctioning shunts with unambiguous flow or absence of flow at surgery were strongly correlated with ShuntCheck results (sensitivity and specificity to flow of 80% and 100%, respectively, P = .0007, Fisher’s exact test, measure of agreement k = 0.8). However, the thermal determination did not distinguish patients in the suspected malfunction group who received surgery from those who were discharged without surgery (P = .248 by Fisher’s exact test, k = 0.20). Half of the patients seen in routine office visits did not have detectable flow, although none required shunt revision on clinical grounds. Intermittent flow was specifically demonstrated in one subject who had multiple flow determinations.

CONCLUSION: Operative findings show that the technique is sensitive and specific for detecting flow, but failure to detect flow does not statistically predict the need for surgery. A better understanding of the normal dynamics of flow in individual patients, which this device may yield, will be necessary before the true clinical utility of noninvasive flow measurement can be assessed.

Risk Factors for Conversion to Permanent Ventricular Shunt in Patients Receiving Therapeutic Ventriculostomy for Traumatic Brain Injury

Neurosurgery 68:85–88, 2011 DOI: 10.1227/NEU.0b013e3181fd85f4

Intracranial pressure is routinely monitored in patients with severe traumatic brain injury (TBI). Patients with TBI sometimes develop hydrocephalus, requiring permanent cerebrospinal fluid (CSF) diversion. OBJECTIVE: To quantify the need for permanent CSF diversion in patients with TBI. METHODS: Patients who received a ventriculostomy after TBI between June 2007 and July 2008 were identified, and their medical records were abstracted to a database. RESULTS: Sixteen of 71 patients (22.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. The average number of days between ventriculostomy and shunt was 18.3. Characteristics that predispose these patients to require permanent CSF diversion include the need for craniotomy within 48 hours of admission (odds ratio, 5.20; 95% confidence interval, 1.48-18.35) and history of culture-positive CSF (odds ratio, 5.52; 95% confidence interval, 1.19-25.52). Length of stay was increased in patients receiving permanent CSF diversion (average length of stay, 61 vs 31 days; P = .04). Patient discharge disposition was similar between shunted and nonshunted patients. CONCLUSION: In this retrospective study, 22% of TBI patients who required a ventriculostomy eventually needed permanent CSF diversion. Patients with TBI should be assessed for the need for permanent CSF diversion before discharge from the hospital. Care must be taken to prevent ventriculitis. Future studies are needed to evaluate more thoroughly the risk factors for the need for permanent CSF diversion in this patient population.